When pain persists after back surgery, the true cause of the patient's pain needs to be re-evaluated. It may be the case that the surgery was performed to address an issue that was not the true pain generator. It may also be damage from the surgical procedure itself that is causing pain. In a spinal fusion surgery, the mechanical changes to the spine may cause new pain to develop. All these things are considered to evaluate the cause of the post-surgical pain.
Video presented by Zinovy Meyler, DO
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Failed back surgery syndrome is a term that is used to describe pain that starts or persists after spine surgery. The important thing to remember is that spine, in itself, serves a certain purpose; it solves a number of problems, but, as with any other tool, it has its own limitations. So, sequelae of the surgery can cause pain, but also at the same time, surgery cannot address all the pain generators. So in looking at it like this, we can actually turn our attention away from the aspect of the surgery and now refocus on the patient and look at the pain generators in that patient in the context of their life and in the context of their overall function. By looking at it like that, we can actually start treating the pain generators and really get to the source of the majority of the pain that's generated after the surgery.
So what we need to look at is the physiologic changes after the surgery. Those are:
- Depending on the surgery, the mechanics of the spine will change. Now, if it's fusion surgery, then what happens is that two segments, for instance, that are being fused are no longer moving on their own. They are now moving in unison, which in effect creates a single segment. Because that single segment is no longer taking up the work of two segments, separately, it is now functioning as a single segment, which means - and this is for simplicity sake - we can say five segments doing 100% of work and that's 20% per segment, now we eliminate two or three segments, per se, and now 33% falls on each segment. Now you can imagine that with additional force going through that segment, there's going to be motion, more wear-and-tear, and more potential pain caused by that segment. And that's usually referred to as "adjacent segment disease." And that’s one of the post-surgical effects.
- Another effect is the actual tissue damage that can happen after surgery. So, myofascial pains can happen after a separation of tissue. When that tissue comes back together, the connective tissue may cause fibrosis - and that can trap nerves - or in itself become tight and painful. That can be treated in a separate way.
- Going back into the increased motion at separate segments, we have to remember that the motion actually happens across facet joints. Those joints are hinge-like joints - they are small joints - and those joints are just like any other joint in our body, which means it can get inflamed just like any other joint and that usually happens through overuse. Treating those joints usually resolves the pain that is associated with those joints and in that way, we can restore the function that was lost through the inflammation and alleviate the pain.
- There are many other pain generators that need to be looked at and can certainly be treated with appropriate diagnosis and treatment.
Treatment of pain persisting after surgery should be approached in a systematic way. Diagnosing each pain generator and eliminating the pain generators can serve to restore function and eliminate pain and in order to do that, we can employ a number of different tools that are available to us. And those include a wide array of the tools. Now it can be manipulations, it could be physical therapy, at times injections, or at times if we need to things like spinal cord stimulation or implantable pumps that can supply a steady state of medication can be used to control the pain. By using all the tools that are available to us, we can really improve the patient's quality of life by doing two very important things: decreasing the pain and restoring function. That way, they can reintegrate back into life and not be limited by pain or by mobility.